Beruflich Dokumente
Kultur Dokumente
Journal of Oncology
Volume 2015, Article ID 571739, 14 pages
http://dx.doi.org/10.1155/2015/571739
Review Article
Dental Treatment in Patients with Leukemia
Caroline Zimmermann,1 Maria Ins Meurer,2,3
Liliane Janete Grando,2,3 Joanita ngela Gonzaga Del Moral,4
Ins Beatriz da Silva Rath,5 and Silvia Schaefer Tavares6
1
Graduate Program of Dentistry, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
Department of Pathology, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
3
Stomatology Clinic, University Hospital, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
4
Hematology Service, University Hospital, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
5
Department of Dentistry, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
6
Integrated Multidisciplinary Health, Federal University of Santa Catarina, 88040-900 Florianopolis, SC, Brazil
2
1. Introduction
The insertion of dentistry in the multidisciplinary context
of hematology-oncology is an important part of the success
of cancer treatment. Oral complications can compromise
the protocols of chemotherapy, possibly making it necessary
to decrease the administered dose, the change in treatment
protocol, or even discontinuation of antineoplastic therapy,
directly affecting patient survival [1, 2].
The feasibility to perform certain dental procedures in
leukemia patients depends on the overall state of health
of the patient, as well as the stage of the disease and/or
antineoplastic therapy or hematopoietic stem cell transplantation. Despite the expectation of finding a vast literature
on the leukemia/dental relationship, the bibliographic survey
conducted (PubMed, BIREME, Journals Portal CAPES, and
SciELO) resulted in a few articles involving the amplitude of
Journal of Oncology
(chronic GVHD or cGVHD). With deep and long immunosuppression, the patient becomes susceptible to fungal and
viral infections [4].
2.3. Oral Manifestations of Leukemia. In acute leukemias,
gingival hyperplasia is generally observed, localized or
generalized, mainly affecting the interdental papillae and
the marginal gingiva caused by inflammation, or leukemic
infiltration, and may be localized or generalized, the latter being the most frequent form [3, 5]. The infiltration
of leukemic cells may also involve periapical tissues and
simulate, both clinically and radiographically, periapical
inflammatory lesions [6]. In chronic leukemia, the leukemic
infiltrates in oral tissues is less frequent and can be observed:
pallor of the mucosa, soft tissue infections, and generalized
lymphadenopathy [5].
The manifestations of thrombocytopenia are more common when the platelet count is below 50,000 cells/mm3 [12]
and may manifest as bruising, petechiae in the hard and soft
palate, and also spontaneous gingival bleeding, especially if
the platelet count is below 20,000 cells/mm3 [6].
Opportunistic infections with Candida albicans and Herpes viruses are common and can involve any area of the
mucosa. Ulcers can also result from impaired immune
defense in combating normal microbial flora [6].
2.4. Oral Manifestations Related to HSCT. The most common
oral manifestations related to pre-, immediate post-, and late
post-HSCT are summarized in Table 6.
The oral manifestations that may be present are correlated with the phases of HSCT [1]: (1) preconditioning:
oral infections, ulceration, bleeding, and temporomandibular joint dysfunction; (2) neutropenic phase conditioning:
mucositis, dysgeusia, xerostomia, bleeding, oral pain, opportunistic infections, neurotoxicity, and temporomandibular
dysfunction, usually manifesting with high prevalence and
severe forms; at this stage, the patient may develop hyperacute GVHD with further severe oral complications; (3)
engraftment to hematopoietic recovery: opportunistic infections are common and acute GVHD becomes a concern;
bleeding may be present, xerostomia, neurotoxicity, granulomas/papillomas, and temporomandibular dysfunction;
(4) immune reconstitution/recovery from systemic toxicity:
salivary dysfunction, late viral infections, craniofacial growth
abnormalities, cGVHD, and squamous cell carcinoma; and
(5) the long-term survival: in pediatric patients, particularly
children under 6 years, one can observe complications in the
development of bones and teeth; at this stage, recurrence and
malignant neoplasms can be observed.
In the occurrence of GVHD, mucositis, gingivitis, erythema, and pain are usually observed. In cGVHD, the most
common oral manifestations are lichen-type features, hyperkeratotic plaques, mucocele, atrophic mucosa, ulceration [13,
14], fibrosis with limited mouth opening, hyposalivation, and
xerostomia [1316]. In addition, secondary to cGVHD, the
patients have a greater tendency to develop malignancies
[14, 17, 18].
Journal of Oncology
3
The objectives of the pre-antineoplastic treatment dental
evaluation are as follows [1, 3, 5, 2022]:
(1) identify and eliminate sources of existing or potential
infection, without, however, promoting complications or delaying cancer therapy;
(2) educate the patient (or their relatives) about the
importance of maintaining oral health in reducing
problems and oral discomfort before, during, and
after cancer treatment;
(3) warn about the possible effects of antineoplastic
therapy in the oral cavity, such as mucositis;
(4) identify specific issues of the diagnosis of leukemia,
such as leukemic infiltrates in oral tissues.
Injury prevention and oral infections is the focus of dental
treatment in leukemic patients and the care with oral hygiene
(brushing, use of fluoride, and noncariogenic diet) should be
emphasized throughout treatment [1, 5, 19].
Data from the US National Cancer Institute [2] allege
that some cancer centers encourage tooth brushing and
flossing, while others indicate the interruption of brushing
and flossing when blood components have a drop below
specified limits (e.g., platelets <30,000 cells/mm3 ). However,
according to the institute itself, there is no evidence in the
literature regarding the best approach. The centers providing
strategy argue that the benefits of proper brushing and
proper flossing outweigh the risks, because the interruption
of routine oral hygiene increases the risk of infection, and
this could promote bleeding as well as increase the risk of
local and systemic infection. Elad et al. [23] agreed that
dental treatment prior to HSCT is preferred to no dental
intervention.
3.2. Oral Health Care during Antineoplastic Treatment.
Patients undergoing chemotherapy have become immunosuppressed and therefore susceptible to systemic infections.
They are classified as high-risk patients, not only by the
possibility of developing infection, but the extent and severity
of this potential, which can have quick course and be
potentially fatal [24].
The objectives of dental care during chemotherapy are as
follows [1]:
(1) maintain optimal oral health;
(2) treat side effects of antineoplastic therapy;
(3) reinforce to the patient the importance of oral
health in reducing problems/discomforts arising from
chemotherapy.
Apart from oral mucositis, the main oral complication
of chemotherapy, other changes may occur, such as bleeding, increased rates of caries, infections (bacterial, viral,
or fungal), gingival abscesses, recurrent herpetic stomatitis,
candidiasis, salivary gland dysfunction, xerostomia, dysgeusia, and pain [2, 3, 20, 24]. It is important to realize
that infections in the oral cavity can progress to systemic
infections, worsening the health status of the patient, and the
presence of a dentist and/or stomatologist provides important
support to the medical staff [2, 3, 21, 25, 26].
Journal of Oncology
was observed among authors regarding the amounts considered minimal for invasive dental procedures in the pre- and
transchemotherapy phases. Tables 1 and 2 show the variation
as well as meeting the recommendations regarding the need
for transfusions, antibiotic prophylaxis, and postponement of
dental treatment [13, 5, 22, 3234].
These explained variations will be presented and discussed in Tables 3, 4, and 5, constructed for each phase of
treatment.
Journal of Oncology
Table 1: Minimum haematological values for performance of invasive dental procedures in prechemotherapy treatment patients according
to different authors.
Authors
Eversole et al., 2001 [33]
Little et al., 2007 [5]
Platelet count
<50,000 cell/mm3 : not perform dental or
periodontal surgery in office setting.
<50,000 cell/mm3 : avoid invasive procedures.
<40,000 cell/mm3 : perform transfusions in invasive
procedures.
US National Cancer
Institute, 2011 [2]
Neutrophil count
Table 2: Minimum hematological values for performing invasive dental procedures in patients undergoing chemotherapy, according to
different authors.
Authors
Sonis et al., 1995 [3]
Haytac et al., 2004 [32]
Brennan et al., 2008 [22]
Koulocheris et al., 2009
[34]
Platelet count
<100,000 cell/mm3 : elective dental treatment should
be postponed.
<40,000 cell/mm3 : periodontal probing and dental
extractions contraindicated.
<50,000 cell/mm3 : contraindication to perform
invasive procedures.
Neutrophil count
<3,500 cell/mm3 (leukocytes): elective dental
treatment should be postponed.
<1,500 cell/mm3 : periodontal probing and dental
extractions contraindicated.
<1,000 cell/mm3 : contraindication to perform
invasive procedures.
Journal of Oncology
No restrictions.
No restrictions.
Orthodontics
Type III
Endodontics
Symptomatic tooth
Asymptomatic tooth
Simple extractions
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
Curettage (gingivoplasty)
Type IV
Type V
Multiple extractions
Flap surgery/gingivectomy
Extraction of impacted tooth
Apicoectomy
Single implant placement
Type VI
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
Journal of Oncology
Considerations or restrictions
Time between
cycles
No restrictions.
No restrictions.
Elective treatment.
Consider removing orthodontic appliances.
Symptomatic tooth
Asymptomatic tooth
Orthodontics
Type III
Endodontics
Type IV
Simple extractions
Curettage (gingivoplasty)
Type V
Multiple extractions
Flap surgery/gingivectomy
Extraction of impacted tooth
Apicoectomy
Single implant placement
Type VI
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
3 weeks; minimum
1014 days [5]
2 weeks; minimum
710 days [1]
Journal of Oncology
Table 5: Possibility of dental procedures in postchemotherapy phase.
Intervention in postchemotherapy
Type I
Exam
Clinic
Radiographic
Hygiene instructions
Molding
Type II
Simple restorations (ART)
No restrictions.
No restrictions.
Completed chemotherapy and after two years free of disease, one can restart the
orthodontic treatment
No restrictions.
Need for antibiotic prophylaxis until six months after completion of chemotherapy.
Need for antibiotic prophylaxis until six months after completion of chemotherapy.
Need for antibiotic prophylaxis until six months after completion of chemotherapy.
of infection was not removed. Chronic lesions of odontogenic origin were identified in 79% of patients, where 44%
were considered serious chronic illness; of these, only 4%
had episodes of fever diagnosed as odontogenic in origin,
which were treated with antibiotics without interruption of
chemotherapy. For the authors, these results demonstrated
that patients with chronic odontogenic lesions can safely
undergo chemotherapy without dental procedures, since
the conversion of chronic processes in acute cases was
uncommon and when sharpening occurred it was effectively
treated without interruption of therapy and without adversely
affecting the oncological treatment. This strategy would
significantly change the established protocols, which recommend a more aggressive prechemotherapy dental treatment.
The authors reasoned that, depending on the severity of the
cancer, there may be a need to quickly start chemotherapy to
maximize its therapeutic effects and in that narrow window of
time, the extraction of teeth without potential recovery may
Pre-HSCT
(preconditioning)
Special
considerations
Oral
manifestations
Oral health
Dental
treatment
Immediate post-HSCT
(neutropenic conditioning phase and engraftment to
hematopoietic recovery)
(i) Mucositis
(ii) Dysgeusia
(iii) Xerostomia
(iv) Hemorrhage
(v) Oral pain
(vi) Opportunistic infections
(vii) Neurotoxicity
(viii) Temporomandibular dysfunction
(ix) Acute GVHD.
Late post-HCST
(immune reconstitution/recovery from systemic
toxicity and long-term survival)
Table 6: Special considerations regarding oral complications, oral health, and dental treatment in pre-, immediate post-, and late post-HSCT.
Journal of Oncology
9
10
irritate the soft tissues, removable appliances, or retainers
well adapted may be maintained provided that the patient
has good oral hygiene. Sheller and Williams [36] defend that
orthodontic appliances should be removed.
It is important that the dentist is aware of the signs and
symptoms of periodontal disease, since these can be subtle
when the patient is immunosuppressed [1, 37].
After treatment of acute needs, other procedures such
as smoothing of rough restorations, rounding, or restoration
of tooth fractures may be performed, in addition to the
assessment of dentures. Scaling procedures and root planning
should be performed to prevent periodontal infections, as
well as enhancing oral hygiene instruction and the use of
mouthwash with fluoride in preventing dental caries [3, 5].
4.2. Dental Treatment in the Transchemotherapy Phase.
Table 4 refers to the stage where the patient is undergoing
chemotherapy and lists the dental procedures and restrictions
assigned to it, referring to haematological indices and considering the period between cycles of chemotherapy.
In high-risk patients (active or under leukemia bone
marrow suppression) dental intervention is limited to emergency care. However, oral hygiene must be maintained by the
use of mouthwashes and mild antimicrobial and antiseptic
solutions, in order to promote ulcer healing and minimize
complications from infection. When there is evidence of oral
infection, high-risk patients should receive broad-spectrum
antibiotics intravenously [3, 5]. In UH/UFSC 0.12%, solutionbased nonalcoholic chlorhexidine gluconate is used in the
form of daily mouthwash or applied with gauze or swab.
In patients at moderate risk (maintenance phase), the
myelosuppression peak is most evident, usually after 14 days
of drug administration, and at this time, dental treatment
should be avoided; before or 21 days after the start of
chemotherapy the treatment can be performed; however,
the doctor should be consulted. If the leucocyte count is
below 3,500 cells/mm3 or the platelet count is less than
100,000 cells/mm3 , elective dental treatment should be postponed [3]. According to these authors, type I procedures
can be performed according to standard protocols, since in
types II, III, and IV procedures, antimicrobial prophylaxis is
recommended.
Tong and Rothwell [24] do not recommend routine
antibiotic prophylaxis for dental procedures in patients
undergoing chemotherapy; however, for invasive procedures
such as tooth extractions and other deep periodontal scaling
procedures that can cause significant bleeding and propagation of bacteria into the bloodstream, antibiotic coverage
should be performed.
Koulocheris et al. [34], citing other authors, state that
in oral surgical procedures during chemotherapy, the benefit/risk to the patient must be considered, as well as the consequences of chemotherapy cycles; these procedures should
therefore be planned and agreed on an interdisciplinary level.
Furthermore, the surgical procedure should be the most
conservative possible, with trans and postantibiotic prophylaxis and postoperative platelet transfusion if necessary. It
is claimed, in addition, that an absolute neutrophil count
Journal of Oncology
greater than 1000 cells/mm3 and platelet count of at least
60,000 cells/mm3 are acceptable rates for oral surgeries.
When there is spontaneous bleeding resulting from
minor trauma, the dentist should strive to improve the oral
hygiene of the patient and use local measures to control the
bleeding. If these measures are not sufficient, platelet transfusion may be required [5].
The management for control of oral bleeding includes
the use of vasoconstrictor agents, clots, and tissue guards.
To reduce the flow of blood from bleeding vessels, one can
use epinephrine; to organize and stabilize blood clots, topical
thrombin and/or collagen hemostatic agents can be used;
and to stanch the bleeding sites and protect organized clots,
the application of the mucosa adhesive products, such as
those based on cyanoacrylate, may be performed. The topical
aminocaproic acid can be useful in patients with friable
clots and intravenous administration may be considered,
in some cases, to improve coagulation and the formation
of stable clots [2]. Topical use of tranexamic acid is also
cited as an effective hemostatic in reducing the incidence
of postoperative bleeding in patients taking continuous use
of oral anticoagulants [38, 39]. Coetzee [40] reports the
empirical use of 500 mg crushed tablets ground in moist
cotton at the site of the surgical wound after tooth extraction, or diluted in water for mouthwash, suggesting it as
an option.
4.3. Dental Treatment after Chemotherapy. Table 5 relates the
postchemotherapy period and summarizes the considerations and constraints in the literature for performing dental
procedures.
Patients who were cured of leukemia are considered to
be of low risk and can be met with normal dental treatment
regimens [3]. After completion of cancer therapy and only
after two years free of disease, the orthodontic treatment that
was interrupted can be restarted [36].
Koulocheris et al. [34] suggest that antibiotic prophylaxis
during oral and maxillofacial surgical procedures should be
performed for at least six months after the completion of
chemotherapy.
4.4. Dental Treatment in Different Phases of Chemotherapy
Treatment. Table 7 shows, in summary form, the considerations and limitations related to dental procedures at different
stages of antineoplastic treatment.
Noninvasive procedures do not require additional care
and may be performed at any stage of the disease or
chemotherapy. Fit in this situation the type I (clinical examination, radiographs, and oral hygiene instruction) and type
II procedures (simple restorations, atraumatic restorative
treatmentART, supragingival scaling and prophylaxis) [3].
Since the priority is the treatment of leukemia before the
diagnosis (prechemotherapy phase) or during antineoplastic
treatment, some dental procedures, classified as type I (molding) and type II (orthodontic treatment), are considered
elective for these patients, and even in the postchemotherapy
phase, some restrictions must be considered when related to
orthodontic treatment.
Journal of Oncology
There are procedures, however, that are considered nonsurgical (type III)such as the realization of more complex restorations, scaling, root planning (subgingival), and
endodontic treatmentbut they require special care in the
prechemotherapy and transchemotherapy phases, considering the general state of health and the risk versus benefit to
the patient. Some authors suggest that periodontal procedures such as probing and periodontal scaling could cause
bacteremia [4144]. In addition, the endodontic treatment
protocol for asymptomatic teeth, according to the literature,
is not well established. Thus, the realization of endodontics
has to justify the removal of infectious foci; however, some
professionals prefer, in such situations, to adopt a radical
behavior, performing the extraction of the dental element
in question in order to avoid future complications. In the
postchemotherapy period, these dental procedures can be
performed without restrictions.
Invasive procedures such as simple extractions (type IV),
multiple extractions (type V), or those of an entire arch or
entire mouth (type VI) can be performed, but its execution
is dependent on the patients risk and should therefore the
risk versus the benefit should be considered in specific situations [3]. We believe that gingivoplasty procedures, multiple
extractions (no infectious foci) flap surgery (gingivectomy),
extraction of single or multiple impacted teeth, apicoectomy,
placing implants, and orthognathic surgery are considered
elective treatments before the diagnosis and/or treatment
of leukemia and should not be performed until the patient
completesand maintainstheir antineoplastic treatment
successfully.
11
Table 7: Possibility of dental procedures at various stages of
chemotherapy.
Intervention
Type I
Exam
Clinical
Radiographic
Oral hygiene instruction
Molding
Type II
Simple restorations (ARTs)
Prophylaxis and supragingival
scaling
Orthodontics
Type III
More complex restorations
Scaling and root planning
(subgingival)
Endodontics
Symptomatic teeth
Asymptomatic teeth
Trans
Post
NR
NR
NR
E
NR
NR
NR
E
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
R
R
HI, AP
R
R
HI, AP
NR
R
HI, AP
E, R
HI, AP
R
HI, AP
E, R
HI, AP
R,
HI, AP
EIHR
R,
HI, AP
EIHR
R,
HI, AP
EIHR
EIHR
EIHR
EIHR
R,
HI, AP
EIHR
EIHR
EIHR
EIHR
R,
HI, AP
R,
HI, AP
EIHR
EIHR
EIHR
EIHR
EIHR
EIHR
EIHR
EIHR
R
R
R
NR
NR
NR
Type IV
Simple extractions
Curettage (gingivoplasty)
Type V
Multiple extractions
Pre
Flap surgery/gingivectomy
Extraction of impacted tooth
Apicoectomy
Single implant placement
Type VI
Extraction of an entire arch or both
Extraction of multiple impacted
teeth
Flap surgery
Orthognathic surgery
Placement of multiple implants
R
R
R
R
R
R
R
12
4 mm and bleeding on probing: BOP 10%) and (2) the
presence of gingivitis (PPD 4 mm and BOP > 10%) or
periodontitis (PPD > 4 mm and BOP 10%). Only 28% of
the patients were considered periodontally healthy. Of the
total, 67% of the patients developed bacteremia (diagnosed
by blood samples collected 2 times per week), and group 2
had more frequent episodes during the neutropenia phase
than group 1. The authors suggested that gingivitis and
periodontitis may represent a risk factor for the development of bacteremia, which has also been shown in other
studies [43, 44]. They further stated that the exacerbation of
gingivitis and chronic periodontitis is rare, probably due to
the institution of prophylactic therapy; on the other hand,
common illnesses should not be overlooked, such as potential
underdiagnosed of bacteremia source, particularly during
periods of neutropenia.
Melkos et al. [45] conducted a prospective study of 58
patients undergoing HSCT and evaluated the preexisting
odontogenic lesions, dental care, and the effect of both
on the medical procedure. All patients were referred for a
dental evaluation before the HSCT, being examined by two
experienced dentists through clinical examination (soft and
hard tissues) and radiographic (panoramic and occasionally
for symptomatic periapical teeth). Infectious foci teeth were
considered with periapical and periodontal infection and
those semi-impacted. The type of pretransplant dental work
and the occurrence of posttransplant complications (mucositis, infections, graft versus host disease (GVHD), and relapse
of disease) were evaluated for an average of 50.45 weeks
after the date of transplantation. The protocol for dental
treatment included restoration of active caries and extraction
of nonrestorable teeth and those with advanced periodontal disease; nonvital teeth were endodontically treated or
extracted, whereas periapical lesions were treated endodontically, performing apicoectomy or extraction. Patients were
divided into two groups: (I) no infectious foci or complete
dental treatment before transplantation ( = 36) and (II)
with infectious foci, submitted to transplantation without
dental intervention ( = 22). Posttransplant complications
were observed in 75% of patients in group I and 95.4% in
group II. The impact of infectious outbreaks in the occurrence
of posttransplant infections was not statistically significant,
as well as correlations between decayed, impacted, and
semierupted teeth, fever of unknown origin, mucositis, and
the survival rate of patients with preexisting foci; however,
the infectious foci were significant when associated with
acute GVHD, mainly impacted teeth and periapical lesions.
A higher rate of complications was found in group II,
indicating the importance of evaluation and pretransplant
dental work. It was concluded that dental treatment before
HSCT should not be radical. Restorative and preventative
techniques, however, must be individually adjusted for each
patient.
Yamagata et al. [46] also conducted a prospective study
of 41 patients who were undergoing HSCT using a conservative dental protocol. All patients were evaluated by clinical
examination of the oral soft and hard tissues and, if necessary,
radiographs were requested. Of the 41 patients, 36 required
one or more dental interventions. The following diagnoses
Journal of Oncology
and procedures were performed: 101 carious lesions: 40
were restored and 61 were untreated; 5 pulpitis treated with
endodontics; 10 teeth with apical periodontitis greater than
5 mm and 33 with less than 5 mm: 7 lesions were surgically
removed, 5 teeth were endodontically treated (including two
with symptomatology), and 31 teeth with lesions smaller than
5 mm and asymptomatic received no treatment; 94 teeth with
periodontitis: 6 were extracted and 88 preserved, with survey
monitoring and hygiene education; 21 partially erupted wisdom teeth: 3 presenting symptomatology were removed, the
rest were untreated. All dental procedures were performed up
to 10 days before HSCT, without change interruption or delay
in the planning of the transplant. No patient had signs or
symptoms of odontogenic infection during the immunosuppression period. The authors concluded that the conservative
protocol appeared to be suitable for pre-HSCT patients.
Abdullah and Ahmad [47] conducted a study of 44
pediatric patients. Dental conditions were evaluated by clinical examination before HSCT. In the case of symptomatic
tooth periapical radiographs were performed. Decayed teeth
considered unviable were extracted, and the others were
restored. In patients at high-risk of caries, sealant was applied.
All patients received oral hygiene guidelines. The patients
were evaluated after 1, 3, and 6 months after HSCT. Most
patients (65.9%) needed some type of pre-HSCT dental
treatment, having performed 101 restorations, 13 extractions,
and 19 sealants. Within 6 months of monitoring, 10% of the
patients who did not receive pre-HSCT dental treatment had
odontogenic infection. No cases of odontogenic infection
were observed in patients who previously received dental
care. The authors concluded that the pre-HSCT dental treatment can reduce the occurrence of infection of dental origin,
and it is important to prevent serious infections.
The US National Cancer Institute [48] points out that the
time of reconstitution of the immune system in transplant
patients can range from 6 to 12 months and that the dental
care routine should not be done in this period, including
scaling and periodontal planning. Procedures that produce
aerosol, such as ultrasound equipment and high speed, can
also present a risk of aspiration of debris and bacteria and
cause pneumonia in these patients [19, 48]. If emergency
treatment is required, strategies for reducing aerosol aspiration and antibiotic prophylaxis should be used. Finally, it is
recommended that the use of IgG, antibiotics, corticosteroids,
and/or platelet transfusion should be considered before
implementing invasive procedures [48].
5. Final Considerations
From the literature review conducted, several oral manifestations in leukemic patients arose. These manifestations are
often the first sign of leukemia and may present clinically
as leukemic infiltration in oral tissues as well as simulating
a periapical lesion. Other symptoms may occur such as
pale mucosa, poor wound healing, bleeding (petechiae and
ecchymoses), atypical or recurrent candidiasis, recurrent
herpes infections, and ulcerations in the oral mucosa. During
antineoplastic treatment (chemotherapy, mostly), the main
complication is mucositis.
Journal of Oncology
Other conditions that may also occur include bleeding,
increase the rate of decay, infection, gum abscess, recurrent
herpetic stomatitis, candidiasis, salivary gland dysfunction,
xerostomia, dysgeusia, and pain. In the posttherapy period,
patients are considered cured and usually present no sequelae
of treatment.
Oral manifestations are similar in patients undergoing
HSCT; however, generally these cases are due to long-term
immunosuppression of the patient even after the transplantation. Special features are observed in patients undergoing
allogeneic HSCT, such as cGVHD, which typically manifests
as lichen-type features, hyperkeratotic plaques, mucocele,
and fibrosis with limited mouth opening, and are more likely
to develop malignancies such as squamous cell carcinoma.
Performing dental procedures can offer risk to the patient,
depending on his state of health and phase of therapy.
Furthermore, some procedures offer greater risk than others.
Thus, noninvasive procedures (type I and type II) can be
performed at any stage of the disease or treatment. Type III
procedures may require special care. Finally, invasive procedures (types IV, V, and VI) offer higher risk. In emergency
situations of risk considered, particularly those involving pain
(acute cases), the patient should be assisted, if necessary, in a
hospital setting, with the institution of measures to increase
the hematological indices (transfusions) and, if applicable,
with antibiotic coverage.
In assessing patients for dental procedures, two hematological indices are particularly important: neutrophil and
platelet counts. At low levels of neutrophil counts, and
when the procedure cannot be delayed, prophylactic antibiotic therapy protocols should be considered, being variable
according to the degree of neutropenia; there is no strict
consensus among authors, but most recommended antibiotic
prophylaxis with values less than 1,000 cells/mm3 . In the case
of the platelet count, the authors consider the need for transfusion from indices between 40,000 and 60,000 cells/mm3 .
Thus, we conclude, based on the literature review presented here, that the dental treatment in relation to haematological indices presented by patients with leukemia should
follow some judicious protocols, mainly related to neutrophil
and platelet counts. However, it is noteworthy that many of
these studies are based on expert opinion. The presence of
the dentist in a multidisciplinary team is essential, since we
understand that maintaining oral health contributes significantly to the overall health and improved quality of life for
patients through the use of dental approaches based on scientific evidence, preventive, curative, and palliative in nature.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
References
[1] American Academy of Pediatric Dentistry, Guideline on dental
management of pediatric patients receiving chemotherapy,
hematopoietic cell transplantation, and/or radiation, Journal
of Pediatric Dentistry, vol. 35, no. 5, pp. E185E193, 2013,
http://www.ncbi.nlm.nih.gov/pubmed/24290549.
13
[2] US National Cancer Institute, Oral Complications of Chemotherapy and Head/Neck Radiation, US National Cancer Institute,
2011, http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional.
[3] S. T. Sonis, R. C. Fazio, and L. Fang, Principles and Practice of
Oral Medicine, WB Saunders, 1995.
[4] M. R. Howard and P. J. Hamilton, Leukaemia, in Haematology,
pp. 3366, Elsevier, Philadelphia, Pa, USA, 3rd edition, 2008.
[5] J. W. Little, D. A. Falace, C. S. Miller, and N. L. Rhodus,
Disorders of white blood cells, in Dental Magenement of the
Medically Compromised Patient, pp. 373395, 2007.
[6] B. Neville, D. Damm, C. Allem, and J. Bouquot, Hematologic
disorders, in Oral and Maxillofacial Pathology, pp. 573613,
Elsevier, 3rd edition, 2009.
[7] R. Wasch, W. Digel, and M. Lubbert, Acute lymphoblastic
leukemia (ALL), in Concise Manual of Hematology and Oncology, M. Andreeff, B. Koziner, H. Messner, and N. Thatcher, Eds.,
pp. 400414, Springer, Berlin, Germany, 2008.
[8] K. Heining-Mikesch and M. Lubbert, Acute myeloid leukemia
(AML), in Concise Manual of Hematology and Oncology, M.
Andreeff, B. Koziner, H. Messner, and N. Thatcher, Eds., pp.
415420, Springer, Berlin, Germany, 2008.
[9] W. Lange and C. Waller, Chronic myeloid leukemia (CML),
in Concise Manual of Hematology and Oncology, pp. 432438,
Springer, Berlin, Germany, 2008.
[10] J. Burger and J. Finke, Chronic lymphocytic leukemia (CLL),
in Concise Manual of Hematology and Oncology, pp. 470476,
Springer, Berlin, Germany, 2008.
[11] K. Durey, H. Patterson, and K. Gordon, Dental assessment
prior to stem cell transplant: treatment need and barriers to
care, British Dental Journal, vol. 206, no. 9, article E19, 2009.
[12] J. B. Epstein, L. Vickars, J. Spinelli, and D. Reece, Efficacy
of chlorhexidine and nystatin rinses in prevention of oral
complications in leukemia and bone marrow transplantation,
Oral Surgery Oral Medicine and Oral Pathology, vol. 73, no. 6,
pp. 682689, 1992.
[13] A. H. Filipovich, D. Weisdorf, S. Pavletic et al., National Institutes of Health consensus development project on criteria for
clinical trials in chronic graft-versus-host disease: I. Diagnosis
and staging working group report, Biology of Blood and Marrow
Transplantation, vol. 11, no. 12, pp. 945956, 2005.
[14] N. Treister, C. Duncan, C. Cutler, and L. Lehmann, How we
treat oral chronic graft-versus-host disease, Blood, vol. 120, no.
17, pp. 34073418, 2012.
[15] K. M. Hull, I. Kerridge, and M. Schifter, Long-term oral
complications of allogeneic haematopoietic SCT, Bone Marrow
Transplantation, vol. 47, no. 2, pp. 265270, 2012.
[16] H. S. Brand, C. P. Bots, and J. E. Raber-Durlacher, Xerostomia
and chronic oral complications among patients treated with
haematopoietic stem cell transplantation, British Dental Journal, vol. 207, no. 9, article E17, 2009.
[17] R. A. Abdelsayed, T. Sumner, C. M. Allen, A. Treadway, G. M.
Ness, and S. L. Penza, Oral precancerous and malignant lesions
associated with graft-versus-host disease: report of 2 cases,
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and
Endodontology, vol. 93, no. 1, pp. 7580, 2002.
[18] F. Demarosi, D. Soligo, G. Lodi, L. Moneghini, A. Sardella,
and A. Carrassi, Squamous cell carcinoma of the oral cavity
associated with graft versus host disease: report of a case and
review of the literature, Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontology, vol. 100, no. 1, pp.
6369, 2005.
[19] S. Elad, J. E. Raber-Durlacher, M. T. Brennan et al., Basic
oral care for hematologyoncology patients and hematopoietic
14
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
Journal of Oncology
stem cell transplantation recipients: a position paper from the
joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology
(MASCC/ISOO) and the European Society for Blood and
Marrow Transplantation (EBMT), Supportive Care in Cancer,
vol. 23, no. 1, pp. 223236, 2015.
R. Albuquerque, V. Morais, and A. Sobral, Protocolo de atendimento odontologico a pacientes oncologicos pediatricos
revisao de literatura, Revista de Odontologia da UNESP, vol. 36,
no. 3, pp. 275280, 2007.
D. Martins, M. A. Martins, and L. Seneda, Suporte odontologico ao paciente oncologico: prevencao, diagnostico, tratamento e reabilitacao das sequelas bucais, Prat Hosp, vol. 7, no.
41, pp. 166169, 2005.
M. T. Brennan, S.-B. Woo, and P. B. Lockhart, Dental treatment
planning and management in the patient who has cancer,
Dental Clinics of North America, vol. 52, no. 1, pp. 1937, 2008.
S. Elad, T. Thierer, M. Bitan, M. Y. Shapira, and C. Meyerowitz,
A decision analysis: the dental management of patients prior
to hematology cytotoxic therapy or hematopoietic stem cell
transplantation, Oral Oncology, vol. 44, no. 1, pp. 3742, 2008.
D. C. Tong and B. R. Rothwell, Antibiotic prophylaxis in
dentistry: a review and practice recommendations, Journal of
the American Dental Association, vol. 131, no. 3, pp. 366374,
2000.
M. Paiva, J. Moraes, R. De Biase, O. Batista, and M. Honorato,
Estudo retrospectivo das complicaco es orais decorrentes da
terapia antineoplasica em pacientes do Hospital Napoleao
LaureanoPB, Odontologia Clnico-Cientfica, vol. 6, no. 1, pp.
5155, 2007, http://www.scielo.br/scielo.php?script=sci nlinks
&ref=000139&pid=S1414-462X20130001000020002&lng=pt.
C. Padmini and K. Y. Bai, Oral and dental considerations in
pediatric leukemic patient, ISRN Hematology, vol. 2014, Article
ID 895721, 11 pages, 2014.
Darka, and G. Pinarli, Long-term effects
A. Avsar, M. Elli, O.
of chemotherapy on caries formation, dental development, and
salivary factors in childhood cancer survivors, Oral Surgery,
Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, vol. 104, no. 6, pp. 781789, 2007.
S. Elad, S. B. Jensen, J. E. Raber-Durlacher et al., Clinical
approach in the management of oral chronic graft-versushost disease (cGVHD) in a series of specialized medical centers, Support Care Cancer, 2014, http://www.ncbi.nlm.nih.gov/
pubmed/25417041.
J. B. Epstein, J. E. Raber-Durlacher, A. Wilkins, M.-G. Chavarria, and H. Myint, Advances in hematologic stem cell transplant: an update for oral health care providers, Oral Surgery,
Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, vol. 107, no. 3, pp. 301312, 2009.
C. Chu, A. H. Lee, L. Zheng, M. L. Mei, and G. C. Chan,
Arresting rampant dental caries with silver diamine fluoride in
a young teenager suffering from chronic oral graft versus host
disease post-bone marrow transplantation: a case report, BMC
Research Notes, vol. 7, article 3, 2014.
J. C. Atkinson, M. Grisius, and W. Massey, Salivary hypofunction and xerostomia: diagnosis and treatment, Dental Clinics of
North America, vol. 49, no. 2, pp. 309326, 2005.
M. C. Haytac, M. C. Dogan, and B. Antmen, The results
of a preventive dental program for pediatric patients with
hematologic malignancies, Oral Health & Preventive Dentistry,
vol. 2, no. 1, pp. 5965, 2004.
L. Eversole, Bleeding disorders, in Essentials of Oral Medicine,
S. Silverman, L. R. Eversole, and E. L. Truelove, Eds., pp. 6166,
BC Decker, London, UK, 2nd edition, 2001.
[34] P. Koulocheris, M. C. Metzger, M. R. Kesting, and B. HohlwegMajert, Life-threatening complications associated with acute
monocytic leukaemia after dental treatment, Australian Dental
Journal, vol. 54, no. 1, pp. 4548, 2009.
[35] J. A. Toljanic, J. F. Bedard, R. A. Larson, and J. P. Fox, A
prospective pilot study to evaluate a new dental assessment and
treatment paradigm for patients scheduled to undergo intensive
chemotherapy for cancer, Cancer, vol. 85, no. 8, pp. 18431848,
1999.
[36] B. Sheller and B. Williams, Orthodontic management of
patients with hematologic malignancies, American Journal of
Orthodontics and Dentofacial Orthopedics, vol. 109, no. 6, pp.
575580, 1996.
[37] J. E. Raber-Durlacher, A. M. G. A. Laheij, J. B. Epstein et
al., Periodontal status and bacteremia with oral viridans
streptococci and coagulase negative staphylococci in allogeneic
hematopoietic stem cell transplantation recipients: a prospective observational study, Supportive Care in Cancer, vol. 21, no.
6, pp. 16211627, 2013.
[38] F. W. G. Costa, R. R. Rodrigues, L. H. T. de Sousa et al., Local
hemostatic measures in anticoagulated patients undergoing
oral surgery. A systematized literature review, Acta Cirurgica
Brasileira, vol. 28, no. 1, pp. 7883, 2013.
[39] G. Ramstrom, S. Sindet-Pedersen, G. Hall, M. Blomback,
and U. Alander, Prevention of postsurgical bleeding in oral
surgery using tranexamic acid without dose modification of oral
anticoagulants, Journal of Oral and Maxillofacial Surgery, vol.
51, no. 11, pp. 12111216, 1993.
[40] M. J. Coetzee, The use of topical crushed tranexamic acid
tablets to control bleeding after dental surgery and from skin
ulcers in haemophilia, Haemophilia, vol. 13, no. 4, pp. 443444,
2007.
[41] A. C. R. T. Horliana, L. Chambrone, A. M. Foz et al., Dissemination of periodontal pathogens in the bloodstream after
periodontal procedures: a systematic review, PLoS ONE, vol. 9,
no. 5, Article ID e98271, 2014.
[42] C. G. Daly, D. H. Mitchell, J. E. Highfield, D. E. Grossberg, and
D. Stewart, Bacteremia due to periodontal probing: a clinical
and microbiological investigation, Journal of Periodontology,
vol. 72, no. 2, pp. 210214, 2001.
[43] D. F. Kinane, M. P. Riggio, K. F. Walker, D. MacKenzie, and
B. Shearer, Bacteraemia following periodontal procedures,
Journal of Clinical Periodontology, vol. 32, no. 7, pp. 708713,
2005.
[44] C. Daly, D. Mitchell, D. Grossberg, J. Highfield, and D. Stewart,
Bacteraemia caused by periodontal probing, Australian Dental Journal, vol. 42, no. 2, pp. 7780, 1997.
[45] A. B. Melkos, G. Massenkeil, R. Arnold, and P. A. Reichart,
Dental treatment prior to stem cell transplantation and its
influence on the posttransplantation outcome., Clinical oral
investigations, vol. 7, no. 2, pp. 113115, 2003.
[46] K. Yamagata, K. Onizawa, H. Yoshida et al., Dental management of pediatric patients undergoing hematopoietic stem cell
transplant, Pediatric Hematology and Oncology, vol. 23, no. 7,
pp. 541548, 2006.
[47] S. Abdullah and Z. Ahmad, Protocol for dental treatment
before bone marrow transplantation (BMT) in paediatric
patient, Pakistan Oral & Dental Journal, vol. 34, no. 3, pp. 399
405, 2014.
[48] National Cancer Institute (US), Posttransplantation Dental
Treatment, http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional/page11.